Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER CHC-73 November 2005 TO: Community Health Centers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Community Health Center Manual (Changes to Program Regulations) This letter transmits revisions to the Community Health Center Manual program regulations. These revisions are effective for dates of service on or after December 1, 2005. Effective December 1, 2005, audiologists providing services under 130 CMR 405.462 should refer to the regulations at 130 CMR 426.404 in the Audiologist Manual for provider eligibility requirements. This letter also transmits a revised Appendix E: Utilization Management Program. Minor revisions are being made for consistency with other MassHealth publications. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net,or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Community Health Center Manual Pages 4-23, 4-24, E-1, and E-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Pages 4-23 and 4-24 — transmitted by Transmittal Letter CHC-72 Pages E-1 and E-2 — transmitted by Transmittal Letter CHC-62 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series COMMUNITY HEALTH CENTER MANUAL SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 405.000) PAGE 4-23 TRANSMITTAL LETTER CHC-73 DATE 12/01/05 405.451: Electrocardiogram (EKG) Services: Introduction The MassHealth agency will pay for an electrocardiogram (EKG) service only when the service is provided at the written request of a CHC staff physician who will interpret or review the interpretation of the EKG. Documentation of the physician’s request must be kept in the member's medical record. 405.452: Electrocardiogram (EKG) Services: Eligibility to Provide Services A CHC may claim payment for electrocardiogram (EKG) services only when both of the following conditions are met. (A) The CHC owns or rents its own EKG equipment. (B) The EKG is taken at the CHC or at the member's home. 405.453: Electrocardiogram (EKG) Services: Payment Limitations (A) The maximum allowable fees include payment for both the technical and professional components of the service. The test must be performed at the CHC and interpreted by a physician employed by the CHC. (B) A CHC must not bill for a visit when a member is being seen for an EKG only. (130 CMR 405.454 through 405.460 Reserved) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series COMMUNITY HEALTH CENTER MANUAL SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 405.000) PAGE 4-24 TRANSMITTAL LETTER CHC-73 DATE 12/01/05 405.461: Audiology Services: Introduction In order for a CHC to be paid for an audiology service other than a hearing test performed as part of an EPSDT services assessment (see 130 CMR 450.140 through 450.149), a written request must be made by a physician, nurse practitioner, or physician assistant who has found some indication of a hearing problem. Documentation of the request and of the hearing problem must be kept in the member's medical record. 405.462: Audiology Services: Eligibility to Provide Services (A) A CHC may claim payment for a basic puretone (air and bone) evaluation by audiometer furnished to a member only when the following conditions are met. (1) The CHC possesses on its premises a puretone audiometer, which must be calibrated at least once every six months. Records of calibrations must be kept and made available to the MassHealth agency upon request. The machine must be placed and testing conducted in a quiet room. (2) The person conducting hearing evaluations is trained to perform hearing tests with an audiometer. (3) The quality of the tester's work is assessed at least twice a year by an audiologist licensed or certified in accordance with 130 CMR 426.404. The audiologist may be a consultant to the CHC. (B) A CHC may claim payment for conducting acoustic impedance testing only when the following conditions are met. (1) The test is conducted by an ASLHA-certified audiologist on the premises of the CHC. (2) The test is conducted by means of a functioning impedance bridge that is placed in a quiet room. (C) If a problem or abnormality is detected or believed to be present after completion of either the basic puretone evaluation or the acoustic impedance test or both, the member must be referred to an otologist or an otolaryngologist for a more complete audiological evaluation and treatment as necessary. 405.463: Audiology Services: Payment Limitations (A) Audiology services that are not listed in Subchapter 6 of the Community Health Center Manual are not reimbursable when furnished in a CHC. (B) A CHC must not bill for a visit when a member is seen for audiology services only. (130 CMR 405.464 and 405.465 Reserved) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series COMMUNITY HEALTH CENTER MANUAL SUBCHAPTER NUMBER AND TITLE APPENDIX E: UTILIZATION MANAGEMENT PROGRAM PAGE E-1 TRANSMITTAL LETTER CHC-73 DATE 12/01/05 Information Required for Admission Screening The following is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening. * the member's name and address * the member's sex * the member's date of birth * the member’s MassHealth identification number * the guardian's name and address, if applicable * if applicable, the name of the member’s primary care clinician (PCC) and one of the following:* * the telephone number of the PCC; * the provider number of the PCC; or * the address of the PCC. * if applicable, whether the PCC has been notified of the proposed admission * other health-insurance information * whether the member is being treated as a result of an accident, and if available, the date and type of accident * the expected or actual dates of admission and discharge * the name and provider number of the attending physician * the name of the hospital * the primary and secondary diagnoses * the primary and secondary procedures, if applicable * the ICD-9-CM codes for both the diagnoses and procedures, if available * clinical information that supports the medical necessity of the proposed admission and/or procedure * other pertinent information the admitting provider has considered in deciding to admit the member *Please note: Information about the member’s PCC is not required if the admission is for dental, oral-surgery, family-planning, or abortion services. Contact for Utilization Management Program Contact information for the MassHealth Utilization Management Program contractor is given below. (See 130 CMR 450.207 through 450.209 for the Utilization Management Program regulations.) MassPRO, Inc. 235 Wyman Street Waltham, MA 02451-1231 Telephone: 1-800-732-7337 Fax: 1-800-752-6334 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series COMMUNITY HEALTH CENTER MANUAL SUBCHAPTER NUMBER AND TITLE APPENDIX E: UTILIZATION MANAGEMENT PROGRAM PAGE E-2 TRANSMITTAL LETTER CHC-73 DATE 12/01/05 This page is reserved.